1. MUCLUC Chng 1. Cp
cu........................................21 1. Cp cu ngng tun hon
c bn............23 2. Cp cu ngng tun hon nng cao........27 3. Cp cu
hn m........................................32 4. Cp cu h ng
huyt..........................36 5. Cp cu t qu n sm (trong vng 3
gi)......................................39 6. Cp cu au ngc
cp..............................42 7. Cp cu au bng
cp..............................46 8. Cp cu cn au qun thn
cp..............49 9. Tc ng mch phi cp...........................
51 10. Cp cu xut huyt tiu ha cao.............. 55 11. Cp cu sc gim
th tch........................60 12. Cp cu ban u sc nhim
khun..........63 13. Cp cu kh th cp................................
67 14. Tc ng h hp trn.............................71 15. Cp cu ban
u suy h hp cp........... 73 16. Cp cu t cp bnh phi tc nghn mn
tnh.....................................................78 Chng 2.
Hi sc TCH cc..........................81 17. Hi chng suy h hp cp
tin trin........83 18. Suy h hp nng do t cp ca bnh phi tc nghn mn
tnh...................86 19. Vim phi nng do vi khun ti cng
ng................................... 89 20. Vim phi nng do virus
cm A................93 21. Vim phi lin quan n th my (VAP)... 96 22.
Trn kh mng phi bnh nhn th
my....................................................100 23. Sc
phn v.............................................102 24. Sc nhim
khun.....................................105 25. Suy thn cp trong
hi sc.....................108 26. Cn nhc c
nng................................113 27. Hn m tng p lc thm thu
ngi i tho ng......................... 116 28. Hn m nhim toan ceton
do i tho ng................. ..................... 119 29. Hi chng
Hellp....................................... 121 30. Hi chng tiu c
vn cp..................... 124 31. Tng p lc ni
s...................................127 32. Hi chng Guillain -
Barr.......................130 33. Vim ty cp
nng..................................133 34. Suy gan
cp...........................................'.137 35. Tng natri
mu........................................ 140 36. H natri
mu.............................................142 37. Tng kali
mu.......................................... 145 38. H kali
mu.............................................. 147 39. Tng calci
mu........................................ 150 Chng 3. Chng c
...................................153 40. Ng c
cp.............................................155 41. Ng c cp
Ethanol................................160 42. Ng c kh carbon
monoxide (CO)......163 43. Ng c cp
opioid..................................166 44. Ng c cp
nereistoxin......................... 168 45. Ng c cp ha cht tr su
Phospho hu c......................................170 46. Ng c cp
ha cht dit chut natri flouroacetat v
flouroacetamid................173 47. Ng c cp ha cht dit chut loi
mui phosphua (phosphua km, phosphua
nhm)................................... 176 48. Ng c cp-ha cht dit
chut loi wafarin............................................... 180
49. Rn h mang cn....................................182 50. Rn cp
nia cn...................................... 185 51. Rn lc
cn.............................................. 188 52. Ong
t.................................................... 190
2. 53. Ng c mt c trm................................193 54. Ng
c cp barbituric.............................195 55. Ng c cp
acetaminnophen
(paracetamol)...........................................198 56. Ng
c cp Rotundin.............................202 57. Ng c nm
c.....................................204 58. Ng c cp Paraquat qua
ng tiu ha..................................................... 207
Chng 4. Tim mch...................................... 211 59. Tng
huyt p..........................................213 60. Tng huyt p
ph n mang thai........217 61. Ri lon lipid
mu....................................220 62. Thp tim
...................................................226 63. Ph phi
cp huyt ng....................... 230 64. au tht ngc khng n nh v
nhi mu c tim khng c ST chnh ln................233 65. Nhi mu c tim
cp............................... 237 66. Hp van hai
l..........................................244 67. H van hai
l............................................249 68. Hp van ng mch
ch......................... 253 69. H van ng mch
ch...........................258 70. Thng lin
nh..........................................263 71. Thng lin
tht.........................................267 72. Cn ng ng
mch................................ 271 73. Hp van ng mch
phi........................ 274 74. Nhp nhanh
tht....................................... 279 75. Nhp nhanh trn
tht................................ 283 76. Ri lon nhp tim
chm...........................289 77 Ngoi tm
thu...........................................295 78. Bloc nh tht
............................................299 79. Hi chng suy nt
xoang....................... 306 80. Rung
nh...................................................310 81. Vim ni
tm mc nhim khun.............314 82. Huyt khi tnh mch su chi
di........318 83. Bnh ng mch chi di mn tnh.......323 84. Tai bin
mch mu no............... 329 85. Phnh tch ng mch
ch......................333 86. Vim mng ngoi tim
.............................. 339 87. Vim c tim
............................................. 342 Chng 5. H
HP......................................... 345 88. Vim ph qun
cp..................................347 89. Vim phi mc phi cng
ng........... 350 90. p xe
phi................................................354 91. Bnh phi
tc nghn mn tnh...............358 92. t cp bnh phi tc nghn mn tnh ti
khoa ni.............................................. 362 93. Gin
ph qun.........................................364 94. Hen ph
qun..........................................370 95. Trn dch mng
phi............................... 375 96. Trn kh mng
phi..................................379 97. Trn m mng
phi................................. 383 98. Ung th ph qun nguyn
pht..............387 99. Tm ph
mn...........................................391 100. Ho ra
mu.............................................. 395 101. Ho ko
di............................................. 399 102. Tng p ng
mch phi.................... 402 103. Bnh
sarcoid..........................................405 Chng 6. Ni TIT
- i tho ng........409 104. i tho
ng......................................411 105. Cc bin chng cp tnh
do i tho ng giaion u................417 106. Bin chng mch mu ln do
i tho ng..................................... 423 107. Bin chng mch
mu nh do i tho dng..................................... 427 108.
Bnh Basedovv..................................... 433 109. Suy
gip.................................................437 110. Bu nhn
tuyn gip..........................442 111. Ung th tuyn
gip............................... 445 112. Vim tuyn
gip.....................................448 113. Bnh to cc vin
cc.............................452 114. Suy tuyn
yn........................................456 115. i tho
nht.........................................460 116 Cng cn gip tin
pht.....................463 117. Suy cn
gip.........................................466 118. Hi chng
Cushing............................... 469 119. Suy thng
thn....................................473 120. u ty thng
thn.................................477 Chng 7. Tiu
HA.......................................481 121. Lot d dy - hnh t
trng..................483 122. Vim ty
cp..........................................487 123. Vim ty mn
tnh.................................492 124. X
gan.................................................. 494 125. Xut
huyt tiu ha cao........................ 498 126. Xut huyt tiu ho do
lot d dy - t
trng...................................................502 127. Xut
huyt tiu ho cao do tng p lc tnh mchca.....................506
3. 128. Bnh co tht tm v...............................509 129.
p xe gan do amip............................... 511 130. Nhim trng
ng mt.......................514 131. Vim gan virus B mn
tnh................... 517 132. Vim gan virus c mn
tnh................... 522 133. Tiu chy cp ngi ln..................
526 134. Vim lot i - trc trng chy mu....530 135. Polyp thc qun, d
dy v rut non .. .534 136. Polyp i trng v mt s hi chng polyp hay
gp......................538 137. Ung th thc
qun................................ 542 138. Ung th i - trc
trng........................ 545 139. Ung th phc mc
nguynpht............ 550 140. Ung th biu m t bo
gan................. 553 141. Bnh
tr...................................................558 142. To
bn..................................................560 143. Lao
mng bng......................................563 144. Hi chng gan
thn............................. 567 C hng 8. Thn - Tit
niu.........................571 145. i
mu..................................................573 146. Vim
bng quang cp...........................576 147. Vim thn - b thn
cp........................579 148. Suy thn
cp..........................................583 149. Vim cu thn
lupus.............................586 150. Hi chng thn
h............................... 589 151. Si tit
niu............................................592 152. H huyt p
trong thn nhn to......... 596 153. Vim phc mc bnh nhn lc mng bng
lin tc ngoi tr................ 599 154. Thiu mu v iu tr thiu mu bng
Erythropoietin bnh nhn suy thn
mn.........................................601 155. Nang n
thn...................................... 604 C hng 9. C X ng
Khp........................ 607 156. Vim khp dng
thp............................609 157. Vim ct sng dnh
khp.....................614 158. Vim khp phn
ng.............................617 159. Vim khp thiu nin t
pht...............620 160. Vim quanh khp
vai............................625 161. Vim mng hot dch khp gi mn
tnh khng c hiu...................... 629 162. Long
xng.........................................633 163. Thoi ha ct
sng............................... 637 164. Thoi ha khp
gi............................... 642 165. au ct sng tht
lng........................ 647 166. au thn kinh
ta..................................650 167. Bnh
gt................................................653 168. Bnh l
vim im bm gn, phn mm quanh khp......................... 658 169.
Hoi t v khun chm xng i......663 170. Vim khp vy
nn............................... 666 171. Bnh still ngi
ln...........................668 172. Lao ct
sng.........................................671 173. Lao khp
gi..........................................675 174. Nhc
c.............................................. 678 175. Vim xng ty
nhim khun..............682 176. Vim khp nhim
khun....................... 686 177. Vim c nhim khun - p xe
c........690 178. Ung th di cn xng..........................693
179. Lon dng c.....................................696 180. Vim a c
v vim da c...................699 Chng 10. T ruyn nhim.........
.............. 703 181. Bnh thy
u....................................... 705 182. Bnh do nm
Candida..........................708 183. Vim gan virus
cp................................711 184. Bnh quai
b...........................................716 185. Vim no herpes
simplex......................720 186. Vim mng no do nm cryptococcus
neotormans.....................723 187. Bnh do nm Penicillium
marneffei.....726 188. Vim mng no tng bch cu i toan.728 189. Nhim
khun huyt............................... 731 190. Vim mng no
m............................... 736 191. Bnh un
vn........................................742 192. Nhim trng do t
cu vng (Staphylococcus aureus).......................748 193. Bnh
st m...........................................753 194. Bnh thng
hn..................................756 195. Bnh l trc
khun................................ 760 Chng 11. D NG Min dch lm
sng.,.763 196. X cng b h thng tin trin..............765 197. D ng
thuc..........................................769 198. Lupus ban h
thng......................... 775 199. My
ay.................................................779 200. Ph
Quincke d ng.............................. 783 201. Vim mch d
ng............................ 787 202. Vim gan t
min..................................791 203. Vim da d
ng...................................... 796
4. CC T VIT TT Chng 1: Cp cu NTH: Ngng tun hon NKQ: Ni kh qun
TM: Tnh mch HSTP: Hi sinh tim phi HA: Huyt p NMCT: Nhi mu c tim MC:
ng mch ch THA: Tng huyt p TMP: Tc ng mch phi T: i tho ng TKMP: Trn
kh mng phi XHTH: Xut huyt tiu ha TMTQ: Tnh mch thc qun CVP: p lc
tnh mch trung tm SNK: Sc nhim khun ARDS: Hi chng suy h hp tin trin
COPD: Bnh phi tc nghn mn tnh Chng 2: Hi sc tch cc ARDS: Hi chng suy
h hp tin trin ALI: Tn thng phi cp ECMO: Tim phi nhn to BPTNMT: Bnh
phi tc nghn mn tnh TKNT: Thng kh nhn to CVVH: Lc mu lin tc BC: Bch
cu ALTMTT: p lc tnh mch trung tm STC: Suy thn cp HTOTC: Hoi t ng
thn cp TM: Tnh mch HMTALTT: Hn m tng p lc thm thu T: i tho ng TCV:
Tiu c vn BN: Bnh nhn ALNS: p lc ni s ALTMN: p lc ti mu no HATB:
Huyt p trung bnh HA: Huyt p HATT: Huyt p tm thu HATTr: Huyt p tm
trng VTC: Vim ty cp ALOB: p lc bng CT: Chp ct lp vi tnh Chng 3:
Chng c BN: Bnh nhn HA: Huyt p TM: Tnh mch ALTMTT: p lc tnh mch
trung tm CVVH: Lc mu lin tc ALTT: p lc thm thu CO: Carbon monoxid
PPHC: Phospho hu c TKT: Thn kinh trung ng PAM: Pralidoxime TMC: Tnh
mch chm INR: Prothrombin HTKN: Huyt thanh khng nc NKQ: Ni khi qun
Chng 4: Tim mch THA: Tng huyt p HA: Huyt p HATT: Huyt p tm thu
HATTr: Huyt p tm trng
5. BMV: ng mch vnh NT: Nhim trng YTNC: Yu t nguy c M: ng ng mch
BMV: Bnh mch vnh CM: Cn ng ng mch HDL: Lopoprotein phn t lng cao
XQ: Xquang LDL: Lopoprotein phn t lng thp CATTT: Chnh p tm thu ti a
HDL-C: HDL-cholesterol TP-MP: Tht phi v ng mch phi LDL-C:
LDL-cholesterol NNVLNT: Nhp nhanh vo li nh tht LP(a): Lipoprotein a
NNTT: Nhp nhanh trn tht ADR: Tc dng khng mong mun BLN: Bloc nhnh
TG: Triglycerid RLNT: Ri lon nhp tim WHO: T chc Y t Th gii TBMN:
Tai bin mch mu no TTT: Thi tm thu RN: Rung nh HoHL: H van hai l NX:
Nt xoang HoC: H van ng mch ch QRS: Tn s tim . CTM: Cng thc mu NP:
Nh phi ASLO: Antistreptohyaluronidase TNT: To nhp tim HHL: Hp van
hai l NTT: Ngoi tm thu NMCT: Nhi mu c tim HCSNX: Hi chng suy nt
xoang NKQ: Ni kh qun tPHNX: Thi gian phc hi nt xoang HFQ: Hp ph qun
rDTXN: Thi gian dn truyn xoang nh CPAP: Th my khng xm nhp HKTM:
Huyt khi tnh mch TM: Tnh mch HKTMSCD Huyt khi tnh mch sau chi COPD:
Bnh phi tc nghn mn tnh di TNK: au tht ngc khng n nh TBMMN: Tai bin
mch mu no T: in tim BN: Bnh nhn LMWH: Heparin c trng lng phn t M:
ng mch thp CT: Ct lp vi tnh HCMVC: Hi chng mch vnh cp MRI: Chp cng
hng t TLT: VLT: Thng lin tht Vch lin tht STQ: Siu m thc qun CK: AL:
Creatinin kinase p lc Chng 5: H hp ALMP: p lc ng mch phi BK
(Bacille de Koch): Trc khun Lao GS: Gng sc THA: Tng huyt p TB:
Trung bnh BPTNMT (COPD): Bnh phi tc nghn mn tnh MP: ng mch phi
TKNTKXN Thng kh nhn tao khng xm PPC: Ph phi cp nhp KLS Khoang lin
sn GPQ: Gin ph qun TLN: * T: Thng lin nh in tm HPQ: Hen ph qun
6. LL: Lu lng nh k Chng 7: Tiu ha ICS: Corticoid dng theo ng
ht, xt hoc kh dung PUD: Lot d dy hoc t trng hoc ICS + LABA: Dng kt
hp gia corticoid dng phun ht vi thuc gin PPI: c hai Nhm thuc c ch
bm proton ph qun tc dng ko di VTC: Vim ty cp dng theo ng phun ht
(bit CT: Ct lp vi tnh dc trn th trng: Symbicort, MRI: Cng hng t
Seretide) ERCP: Chp mt ty ngc dng TDMP: Trn dch mng phi EUS: Siu m
ni soi LDH: Lactic dehydrogenase ICU: XHTH: TKMP: Trn kh mng phi n
v iu tr tch cc Xut huyt tiu ha CLVT: HC: Ct lp vi tnh Hi chng BN:
Bnh nhn CTM: Xt nghim cng thc mu MSCT: Ct lp vi tnh ngc a u d
NSAIDs: Thuc gim au chng vim TAMP: Tng p ng mch phi khng steroid
Chng 6: Ni tit - i tho ng ALTMC: TMTQ: p lc tnh mch ca Tnh mch thc
qun T: i tho ng VGVRBMT: Vim gan virus B mn tnh GM: Glucose mu HBV:
Virus vim gan B HA: Huyt p HCV: Virus vim gan c THA: Tng huyt p
GFR: Mc lc cu thn TZD: Thiazolodinedion VLTTCM: Vim lot i - trc
trng chy DPP IV: Dipeptidyl peptidase IV mu ALTT: p lc thm thu
UTTT: Ung th i trc trng ACE: Thuc c ch men chuyn PEI: Tim cn tuyt i
ARBs: Chn th th Angiotensin RFA: t nhit khi u gan bng sng MRI: Cng
hng t cao tn VTG: Vim tuyn gip HCC: Ung th biu m t bo gan HCGT: Hi
chng gan thn TRAb: Receptor tuyn gip GH: Hormon tng trng AFP: Alpha
fetoprotein GHRH: ADH: Gii phng hormon tng trng Hormon chng bi tit
Chng 8: Thn - Tit niu BT: Bnh thng UPR: Chp b thn ngc dng PTH:
Hormon cn gip trng AG: Chp mch thn MEN: Hi chng a u cc tuyn ni VTBT
cp: Vim thn - b thn cp SCG: tit Suy cn gip UIV: Chp thn niu qun c
thuc HC: Hi chng VCT: cn quang Vim cu thn TT: Thng thn TNT: Thn nhn
to
7. CAPD: Lc mng bng lin tc ngoi HEV: Hepatitis E virus tr ARN:
Virus quai b BN: Bnh nhn HSV: Herpes simplex virus Chng 9: C Xng
Khp DNT: MRI: Dch no ty Cng hng t VCSDK: Vim ct sng dnh khp EEG: in
no MRI: Cng hng t VMN: CT scan: Vim mng no Ct lp vi tnh VKP: Vim
khp phn ng SIRS: Hi chng p ng vim h HLA: Human Leukocyte Antigen
thng AIDS: Acquired Immunodeficiency ALTMTT: p lc tnh mch trung tm
Syndrome DIC: ng mu ni mch ri rc THCS: THK: Thoi ha ct sng Thoi ha
khp VKDT: Vim khp dng thp Chng 11: D ng - Min dch lm sng CSTL: au
ct sng tht lng XCBHT: X cng b h thng CRP: Protein c phn ng HCTH: Hi
chng thn h CVKS : Chng vim khng steroid HC: Hng cu VKVN: Vim khp vy
nn BC: Bch cu TM : Tnh mch TC: Tiu cu VK : Vi khun ANA: Khng th
khng nhn HA: NSAIDs: Huyt p Thuc chng vim khng steroi Lrhng 10:
Truyn nhim XN: Xt nghim VGVR: Vim gan virus Hb: Hemoglabin HAV:
Hepatitis A virus CTM: Cng thc mu HBV: Hepatitis B virus VGTM: Vim
gan t min HCV: Hepatitis c virus SMA: Khng th c trn HDV: Hepatitis
D virus TE: Tr em
8. Chng 1 CP CU BNH VIN BCH MAI
9. CP cu NGNG TUN HON c BN I. I CNG Hi sinh tim phi cn c bt u
ngay lp tc sau khi pht hin bnh nhn ngng tun hon (NTH). Do khong thi
gian t khi gi cp cu n khi kp cp cu c mt cp cu bnh nhn thng trn 5
pht, nn kh nng cu sng c bnh nhn ngng tim ph thuc ch yu vo kh nng v
k nng cp cu ca kp cp cu ti ch. Sc in cp cu ph rung tht s c hiu qu
nht nu c thc hin trong vng 5 pht u sau ngng tim. Hi sinh tim phi kt
hp vi sc in sm trong vng 3 n 5 pht u tin sau khi ngng tun hon c th
t t l cu sng ln n 50% - 75%. II. CHN ON 1. Chn on xc nh da vo 3 du
hiu: mt thc t ngt, ngng th, mt mch cnh. 2. Chn on phn bit - Phn bit
v tm thu vi rung tht sng nh: cn xem in tim trn t nht 2 chuyn o. -
Phn bit phn li in CO vi sc, try mch: cn bt mch 2 v tr tr ln. - Phn
bit mt mch cnh/mch bn do tc mch: cn bt mch 2 v tr tr ln. 3. Chn on
nguyn nhn Song song vi cp cu hi sinh tim phi c bn, cn nhanh chng tm
kim nguyn nhn gy NTH gip cp cu c hiu qu v ngn nga ti pht. Cc nguyn
nhn thng gp v c th iu tr nhanh chng: (xem bng 1) Bng 1. Nguyn nhn
ngng tun hon thng gp 11TtrongtingVit 6H"trongtingAnh
12TtrongtingVit 5'T'trongtiengAnh Thiu th tch tun hon Hypovolemia
Trng c cp Toxins Thiu oxy 1 Hypoxia Tamponade tim Tamponade
(cardiac) Toan mu Hydrogen ion (acidosis) Trn kh mng phi p lc
Tension pneumothorax Tng/Tt kalimu Hyper/Hypokalemia Tc mch vnh,Tc
mch phi Thrombosis (coronary and pulmonary) Tt h ng huyt
Hypoglycemia Thong tch Trauma Thn nhit thp Hypothermia chodnh,
gittl5T6H(tingAnh) hoyl2T (ting Vit)
10. 24 H ng dn chn on v iu tr bnh Ni khoa III. XTRi CP CU - X
tri cp cu NTH c khi ng ngay t khi pht hin trng hp nghi ng NTH. Ngi
cp cu va tin hnh chn on, gi ngi h tr va bt u cc bin php hi sinh tim
phi c bn ngay. - Cn c 1 ngi l ch huy phn cng, t chc cng tc cp cu ng
trnh t v ng b. - Cn ghi chp cc thng tin cn thit v tin trnh cp cu. -
Thit lp khng gian cp cu rng v hn ch ti a cc nhn vin hoc nhng ngi
khng tham gia cp cu vo v lm cn tr cng tc cp cu. 1. Tin hnh ngay hi
sinh tim phi c bn (ABC) ng thi gi h tr khi pht hin bnh nhn nghi ng
b NTH (khng c ng, khng phn ng khi lay gi...) a. Kim sot ng th: t
nga u, c n, th thut ko hm di/nng cm Cn t NKQ cng sm cng tt nhng
khng c lm chm sc in v khng lm gin on p tim/thi ngt qu 30 giy. b.
Kim sot v h tr h hp: thi ngt hoc bp bng Nu bnh nhn khng th: thi ngt
hoc bp bng 2 ln lin tip, sau kim tra mch: - Nu c mch: tip tc thi
ngt hoc bp bng. - Nu khng c mch: thc hin chu k p tim/thi ngt (hoc
bp bng) theo t l 30/2. - Nhp th nhn to (thi ngt, bp bng) thi vo
trong 1 giy, lm lng ngc phng ln nhn thy c vi tn s nhp l 10 -12
ln/pht i vi ngi ln, 12 - 20 ln/pht i vi tr nh v nh nhi. - Sau khi c
ng th nhn to (v d ng NKQ, mt n thanh qun, tn s bp bng l 8 -10
ln/pht v p tim 100 ln/pht, khng cn ngng p tim bp bng. - Ni oxy vi
bng ngay khi c oxy. c. Kim sot v h tr tun hon: p tim ngoi lng ngc.
- Kim tra mch cnh (hoc mch bn) trong vng 10 giy. Nu khng thy mch:
tin hnh p tim ngay. - p tim 1/2 di xng c, ln 1/3 -1/2 ngc (4 - 5cm
vi ngi ln) s thy mch khi p; tn s 100 ln/pht. Phng chm l p nhanh, p
mnh, khng gin on v ngc phng ln ht sau mi ln p. - T l p tim/thng kh
l 30/2 nu l bnh nhn ngi ln hoc bnh nhn tr nh, nh nhi c 1 ngi cp cu.
T l c th l 15/2 i vi tr nh hoc nh nhi c 2 ngi cp cu. - Kim tra mch
trong vng 10 giy sau mi 5 chu k p tim/thi ngt hoc sau mi 2 pht (1
chu k p tim/thi ngt l 30 ln p tim/2 ln thi ngt). 2. Ghi in tim sm
ngay khi c th v sc din ngay nu c ch nh a. Nhanh chng ghi in tim v
theo di in tim trn my theo di. Phn loi 3 loi in tim: rung tht/nhp
nhanh tht, v tm thu, phn li in c. b. Tin hnh sc in ngay nu l rung
tht My sc in 1 pha: s 360J; My sc in 2 pha: 120 - 200J. Tin hnh
ngay 5 chu k p tim/thi ngt sau mi ln sc in. 3. Cc thuc cp cu NTH
(xem bng 2). IV. PHNG BNH NTH thng xy ra t ngt, khng d on trc c. Tt
c cc nhn vin cp cu, nhn vin y t cu h phi c tp luyn v chn b sn sng
cp cu NTH. Cc xe cp cu, cc c s cp cu cn c cc phng tin v thuc cp cu
cn thit cho cp cu NTH.
11. 25Hng dn chn on v iu tr bnh Ni khoa Bng 2. Cc thuc cp cu
NTH Thuc LiutimTM* Liuti a LiuquaNKQ** Chnhchnh Adrenalin 1mg/3 - 5
pht/ln 2-2,5m g Ccloi NTH Amiodaron 300mg 2,2g/24 gi Rung tht tro
Atropin 1mg/3 - 5 pht/ln 3mg 3mg Nhp chm. V tm thu Magne Sulfat 1
-2 g Xon dinh Lidocain (xylocain) 1- 1,5mg/kg 3mg/kg 2 - 4mg/kg
Rung tht Vasopressin 40 UI (1 ln duy nht) Rung tht tr * TM: tnh
mch; * * NKQ: Ni khi qun. Phc hi sinh tim phi cbn ngng tun hon (BIS
algorithm) Mi chu k Hi sinh tim phi hay chu k p tim ngoi lng ngc-
thng kh (CPR) bao gm: 30 ln p tim v 2 ln thi ngt.
12. 26 H ng dn chn on v iu tr bnh Ni khoa Tm tt k thut hi sinh
tim phi cbn (BLS) ABCD Cho tr nh nhi, tr nh, ngi ln (khng gm tr mi
) Kthut Ngilnvtrln Trnh(1n8tui) Trnhnhi 22). - Chy mu khoang di
nhn.
27. H ng dn chn on v iu tr bnh Ni khoa 41 -Huyt p tm thu trn
185mmHg hoc huyt p tm trng trn 110mmHg. - Chn thng cp c chy mu. -
Tiu cu di 100.000. - INR >1,5 ln. -ng mu < 50mg/dl
(2,8mmol/l) hoc trn 400mg/dl (22,2mmol/l). - Chp ct lp vi tnh s no
c bng chng chy mu no hoc nhi mu no > 1/3 bn cu. c. Cch thc tin
hnh - Thuc tiu si huyt c khuyn co dng hin nay l alteplase. - Tnh
liu thuc theo cn nng bnh nhn vi tng liu = cn nng bnh nhn X 0,9mg
(hin nay chng ti ang p dng ti khoa cp cu vi liu 0,6mg theo khuyn co
ca Hip hi t qu Nht Bn). -Tim bolus 10% tng liu trong vng 1 pht, 90%
cn li truyn trong vng 60 pht. 4. Theo di v cc iu tr khc Theo di
huyt p, mch, thn kinh: - Cch 15 pht mt ln trong 2 gi u. - Cc 30 pht
mt ln trong 6 gi tip theo. - Cch 60 pht mt ln trong 16 gi tip theo.
- Duy tr huyt p tm thu di 185mmHg, huyt p tm trng di 110mmHg. - Nu
huyt p > 185mmHg hoc huyt p tm trng > 110mmHg, dng thuc h
huyt p nitroprussid iu chnh. - Theo di huyt p mi 15 pht mt ln khi
truyn thuc h huyt p. - Huyt p nn duy tr tt nht t 160 - 180mmHg/90
-110mmHg duy tr ti mu no. Trong 24 gi u ca dng thuc tiu si huyt:
khng c dng cc thuc chng ng v cc thuc chng ngng tp tiu cu. Khng c
chc ng mch, tnh mch trung tm, t ng thng d dy. Sau 24 gi dng thuc
tiu si huyt, phi chp li phim ct lp vi tnh s no, trc khi quyt nh iu
tr thuc chng ngng tp tiu cu cho bnh nhn. Tm li, chn on v iu tr tt
cho bnh nhn t qu cp, nhn vin y t phi p ng tt v cc mc thi gian: (xem
bng 2) Bng 2. Mc thi gian chn on v iu tr t qu nh gi chung tnh trng
bnh nhn ngay khi n khoa cp cu 10 pht nh gi v thn kinh ngay khi bnh
nhn n khoa cp cu 25 pht Chuyn bnh nhn n phng chp ct lp vi tnh s no
25 pht c kt gu phim chp ct lp vi tnh s no 45 pht Dng thuc tiu si
huyt, tnh thi gian kt khi bnh nhn n khoa cp cu 60 pht Dng thuc tiu
si huyt, tnh thi gian k t khi bnh nhn ctriu chng khi pht 180 pht
Nhp vin vo n nguyn chuyn theo di sau khi iu tr thuc tiu si huyt 180
pht TI LIU THAM KHO 1. L c Hnh v nhm chuyn gia, Tai bin mch no: hng
dn chn on v x tr", Nh xut bn Y hc. 2009: 464-472. 2. Nguyn t Anh,
Mai Duy Tn, Dy chuyn cp cu ban u t qu cp, Y hc lm sng. 2009; 17-21.
3. The ACLS core cases: acute stroke".
28. CP cuAU NGC CP I. I CNG au ngc l triu chng thng gp ti khoa
cp cu, iu kh khn nht l phn bit au ngc nguy him. Nguyn nhn phi loi
tr u tin l hi chng mch vnh cp, do mc nguy him v s din bin nhanh, t
ngt v bt thng. Chn on nguyn nhn au ngc khng bao gi d dng. Do vy, kt
lun phi da vo hi tin s, khm lm sng v cc thm d xt nghim y . II. CHN
ON 1. Thm khm v nh hng chn on a. Triu chng lm sng - M t tnh cht cn
au: do mch vnh thng l tng cn, au bp nght, cng p cho d khng in hnh c
th ch l cm gic kh chu lng ngc tri. au kiu x rch t trc ra sau lng
hoc t sau ra trc ngh ti phnh tch ng mch ch. au nh dao m, do nguyn
nhn phi hoc mng phi hoc h c xng. au kiu rt bng, kh tiu ngh ti nguyn
nhn ng tiu ha. Cn au c lin quan ti hot ng th lc ngh ti thiu mu cc b
c tim, cn au tng dn khi ngh ngh ti nhi mu c tim (NMCT) cp. Cn au t
ngt xut hin c th ngh ti phnh tch ng mch ch (MC), nhi mu phi, trn kh
mng phi. Cn au rt bng xut hin sau n ngh ti bnh l tiu ha. - V tr cn
au: cn au khu tr mt din tch nh ngh ti cn au thnh ngc, cn au vng
ngoi bin lng ngc ngh ti phi hn l tim. au nhi mt im trn lng ngc khng
phi l do nguyn nhn mch vnh. -Tnh cht lan ca cn au: cn au lan ra pha
sau gi phnh tch ng mch ch (MC) au cn nguyn tiu ha. Cn au lan ra cm,
cnh tay hoc c do thiu mu c tim. Cn au gia hai xng b vai lan ln c
ngh ti phnh tch. - Thi gian xut hin cn au: au nhanh vi giy t khi do
tim, cn au d di ngay khi bt u c th do phnh tch ng mch ch, cn au nh
ko di nhiu ngy t khi do nguyn nhn nguy him. - Yu t lm nng ln cn au:
tng ln khi vn ng, gim khi ngh ngh ti suy mch vnh cp, cn a lin quan
ti ba n gi nguyn nhn do tiu ha, cn au tng ln khi ht th ngh ti nguyn
nhn phi, lng ngc, c xng. - Cc yu t phi hp: au ngc km theo nn, bun
nn, v m hi, ngt v kh th thng gi mt nguyn nhn nguy him. au d di km
ho ra mu c th l nhi mu phi, vim phi thy, p xe phi hoc lao. Khai thc
tin s cc bnh phi hp nh tng huyt p (THA), bnh c tim, NMCT c, i tho
ng, tng m mu, ht thuc l...
29. 43H ng dn chn on v iu tri bnh Ni khoa b. Khai thc bnh s v
thm khm Nn tp trung vo cn au + Thi gian bt u. + Kiu v tnh cht cn
au. + Yu t lm tng, gim cn au. + Cc triu chng phi hp. + Cc triu chng
tim mch v yu t nguy c c t trc. - Khm lm sng: ty theo nguyn nhn m ta
c cc du hiu lm sng khc nhau. + Vi nhi mu c tim cp c th bnh nhn vo
trong bnh cnh lon nhp tim, ting thi mi xut hin do h van tim cp hoc
bnh nhn vo trong tnh trng ph phi cp. + Vi phnh tch ng mch ch thy
mch khng tng xng hai bn, h van ng mch ch cp hoc p tim cp nu trn mu
mng tim. Nhi mu phi c th gy bnh cnh kh th, tm, ho ra mu, suy tim
phi cp tnh, tt huyt p. Trn kh mng phi c th khm pht hin lng ngc cng,
r ro ph nang gim, g vang trng... Chn thng: c th thy ng gip, gy xng
sn, bm tm. Vim ty cp: bng trng, phn ng thng v. c. Cn lm sng Cc xt
nghim quan trng nht: in tm , men tim v Xquang tim phi thng. - in tm
: + Nn ghi in tm cho tt c cc bnh nhn au ngc. + Chn on ngay xem c
biu hin in tim ca hi chng mch vnh cp (au ngc khng n nh v NMCT), cc
biu hin lon nhp hay khng. + Trn dch mng ngoi tim thng c biu hin in
th thp hoc bin i in th theo h hp (QRS alternance). + Nhi mu phi ln
thng c biu hin tm ph cp (S1Q3T3: s su DI, Q su Dlll, T su Dlll). -
Men tim: + Tng CK, CK MB, t l CKMB/CK > 10%. + Troponln ng vai
tr cc k quan trng trong loi tr hi chng vnh cp, c hiu cho tn thng c
tim. Ch troponin phi ngoi 4 gi sau khi bt u au mi tng. + Ngoi ra,
cn c myoglobin, LDH hoc GOT/GPT tuy nhin gi tr v c hiu khng cao
trong NMCT. Cc xt nghim khc: - Chp Xquang tim phi thng: c tc dng
loi tr trn kh mng phi hoc nghi ng phnh tch MC (trung tht rng), suy
tim, ph phi, tn thng xng. Hoc i khi thot v honh. Trn kh trung tht.
- Chp CT ngc khi nghi ng phnh tch ng mch ch hoc tn thng trong lng
ngc hoc CT a dy nh gi mch vnh. - Siu m bng: p xe di c honh, vim
ty... 2. Chn on nguyn nhn - Ba cn nguyn phi loi tr: + Hi chng vnh
cp: au ngc khng n nh v NMCT. + Phnh tch ng mch ch. + Tc ng mch
phi.
30. 44 H ng dn chn on v iu tr bnh Ni khoa - Ngoi ra: + Trn kh
mng phi. + Vim c tim, vim mng ngoi tim. + Cn au tro ngc d dy thc
qun. + Vim ty cp. + Zona ngc. + Cc nguyn nhn thnh ngc. + Cc bnh l
phi khc: ng gip, u phi, dy dnh... III. HNG X TR V CP cu -Tt c cc
bnh nhn au ngc phi c u tin phn loi (triage) ngay, bc s nn ti khm
trong vng < 5 pht sau khi bnh nhn ti vin. Cn au c bt k mt trong
cc c im sau phi c u tin cp cu: + C bnh l tim mch hoc nguy c tim mch
r rng. + Cn au c tnh cht ni tng. + C du hiu thc vt (v m hi, nn, bun
nn). + Kh th. + Bt thng v mch v huyt p. - Nhanh chng nh gi v n nh
cc chc nng sng. Thm khm chi tit (bnh s, tin s, khm chi tit) thc hin
sau hoc song song vi vic n nh c chc nng sng. Ch loi tr ban u 3
nguyn nhn nguy him: + Hi chng vnh cp (au tht ngc khng n nh v NMCT).
+ Phnh tch ng mch ch. + Tc ng mch phi. - Nn ch 3 thm d rt gi tr
trong au ngc: + Ghi in tim 12 chuyn o. + Xt nghim men tim: troponin
T, CKMB. + Chp Xquang tim phi. Cc bc x tr khi tip cn vi bnh nhn au
ngc ti khoa Cp cu - Cc x tr cp cu c bn ban u: + Mc monitor theo di
in tim. + Ghi in tm 12 chuyn o, phi xem trong vng 10 pht. + Th oxy.
+ Gim au. + t ng truyn tnh mch. + Ly mu lm xt nghim troponin, CKMB,
ng mu, in gii , chc nng thn. + Cn nhc cho: > Aspirin. >
Nitroglycerin. > Gim au: morphin. Ch : nu c NMCT tht phi khng nn
dng cc thuc morphin hay gin mch nh nitroglycerin. - Cho thuc gim au
sm, s dng thang im au 0-10 im. Yu cu bnh nhn t xc nh mc au t 0
(khng au) ti 10 (au d di nht). - Theo di Sp02, in tim, o huyt p
nhiu ln.
31. 45Hng dn chn oAn v iu tr bnh Ni khoa - iu tr cp cu theo
nguyn nhn + Vi hi chng vnh cp: > Th oxy. > Cho gim au: nn dng
nhm morphin nu khng c chng ch nh. > t ng truyn tnh mch: ly mu lm
cc xt nghim. > Mc monitor theo di in tim phng lon nhp. > Cho
thuc cp cu: phc MONAC gm c morphin, oxy, nitroglycerin, aspirin,
clopidogrel. > Hi chn chuyn khoa tim mch xt can thip cp cu. +
Phnh tch ng mch ch: > Gim au. > Kim sot huyt p. > M cp cu
nu phnh tch Stanford A. + Tc ng mch phi: > Th oxy. > Cho chng
ng sm: heparin sau l khng vitamin K. > Xt ch nh dng tiu si huyt.
> Phu thut nu c ri lon huyt ng. + Trn kh mng phi p lc: chc v m
mng phi cp cu. + Cn au d dy-thc qun: cho thuc khng acid v bc nim mc
d dy. + Vim ty: t ng thng d dy, nhn n, gim au. TI LIU THAM KHO 1. V
Vn inh v cng s. Hi sc cp cu ton tp. Nh xut bn Y hc 2007. 2. Rosen
Emergency Medicine, Me Graw Hill 2006. 3. Current diagnosis and
treatment Emergency Medicine, 6thedition, McGraw Hill 2008.
32. CP cu AU BNG CP I. I CNG au bng cp l mt tnh trng rt hay gp
ti khoa cp cu, nguyn nhn v cng a ng. iu kh khn nht l phn bit c cn
au bng ny c ch nh ngoi khoa hay khng vi cc cn au bng khc. i khi cn
au bng ngoi khoa c biu hin sm rt kn o. Ngoi cc thm d chc nng h tr
chn on, theo di st cc cn au cha loi tr nguyn nhn ngoi khoa gip chng
ta trnh c nhng sai st khng ng c. II. CHN ON CN AU BNG CP Chn on au
bng phi da vo khai thc tin s, khm lm sng v cc xt nghim thm d. -
Khai thc tnh cht cn au Cn au co tht: tng cn, gia cc cn c th ht hoc
m (v d: au qun gan, co tht rut, tc rut...). Cn au kch ng thnh bng:
lin tc, m , khng dt, thng c phn ng (v d: vim phc mc rut tha, chy mu
trong bng, thng tng rng...). Cn au lan: lin quan ti t th, nhp th...
(v d: vim phi, p xe c tht lng chu, trn m mng phi...). - Khai thc v
tr cn au (mi v tr au c gi tr gi tn thng tng bn di). au thng v: vim
d dy, vim ty, nhi mu c tim, thot v, giun chui ng mt,... au h v: vim
bng quang, si bng quang, vim t cung phn ph, cha ngoi t cung,... au
quanh rn: vim d dy-rut,... au h sn phi: p xe gan, giun chui ng mt,
vim ti mt cp,... au h chu phi: vim rut tha, vim manh trng, si niu
qun,... au h chu tri: si niu qun, vim ti tha,... au hai bn mng sn:
si niu qun. - Xc nh mc au: Phi xc nh mc au cho thuc gim au sm. Dng
thuc gip cho chn on d dng v chnh xc hn ch khng phi lm mt triu chng.
'Thang im au yu cu bnh nhn t nh gi. im 0: khng au; im 10: au d di
nht. Yu cu bnh nhn nh gi mc t 0 ti 10 v ghi nhn kt qu: v d 4/10,
7/10. - Khai thc tin s: Thi gian xut hin cn au. Yu t lin quan ba n:
ng c, d ng? Cc bnh l ton thn t trc: vim ty mn, si mt, si
thn,...
33. 47H ng dn chn on va iu tr bnh Ni khoa St? Thiu mu? - Khm lm
sng: Khm k bng (nhn, s, g, nghe) v cc l thot v, trc trng. Tm cc du
hiu ngoi khoa: bng trng, tng nhu ng, quai rut ni, phn ng thnh bng,
cm ng phc mc, thot v nght... Ton thn: thc, mch, HA, nhp th, sc,
thiu mu, toan nng,... - Cn lm sng: Nn la chn ty bnh nhn v nh hng lm
sng: Chp bng khng chun b: tc rut, thng tng rng. Siu m bng: nhiu tc
dng, pht hin bnh l ty, gan, ng mt, ti mt, thn, bng quang, ng mch
ch... siu m nh hng trong chn thng (FAST). Chp ct lp bng: vim ty, si
niu qun, vim rut tha... Chp mch mu: phnh tch ng mch ch (MC), tc mch
mc treo. Xt nghim h tr: cng thc mu, amylase, D dimer, LDH, men
gan,... III. NH HNG CHN ON LM SNG Thng thng bng l c quan c nhiu t
chc bn di, do vy vic chn on ra mt bnh c th da vo lm sng rt kh khn.
S dng cc thm d chc nng xc nh v tm chn on ngy cng quan trng. Thng
tng rng: cn au t ngt d di, lin tc kiu ngoi tng (parietal): bng cng,
phn ng thnh bng. Vim ty cp: au thng v, thng km theo nn nhiu v bng
trng hay gp bnh nhn nghin ru. Tc rut: au bng tng cn kiu ni tng
(visceral), bng trng, b trung, i tin. Tc mt (si ti mt, si ng mt
ch...): au bng mng sn phi, st, vng da i khi khm thy ti mt to, n im
ti mt au. Cn au qun thn: au d di mng sn, lan xung di hoc xung bu,
tiu but rt hoc c mu. Vim rut tha triu chng thng ph thuc vo thi gian
ti khm. Giai on sm i khi ch au vng thng v, st nh; giai on mun hn:
au khu tr h chu phi, n c phn ng r. IV. HNG X TR Xc nh y c phi l au
bng khng n nh: l nhng trng hp au bng c nh hng chc nng sng. V d: -
Tt huyt p, mch nhanh. - Nhim trng - nhim c. -Thiu mu nng. 1 - Ri
lon thc. - Suy h hp. Cc bc cn lm ngay - Mc monitor theo di mch,
huyt p, Sp02, in tim ty theo trng hp c th. - t ng truyn tnh mch, nu
c sc phi t 2 ng ngoi vi c ln. - Nhn n nu bnh nhn c nghi ng ch nh
ngoi khoa.
34. 48 H ng dn chn on va iu tr bnh Ni khoa - Lm cc xt nghim c
bn, ng mu v cc xt nghim cn cho phu thut. - t ng thng d dy dn lu nu
bng trng, cn theo di dch d dy. - Hn ch hoc ch c bit khi di chuyn
bnh nhn i chp chiu, siu m. u tin lm cc thm d ti ch (hn ch ri ro khi
phi chuyn bnh nhn ra ngoi khoa v c th lm nhiu ln theo di tin trin).
- Lu pht hin v x tr hi chng khoang bng cp (tng p lc trong bng). Gim
au y : - Cn cho gim au cp cu nu au > 4/10 - Ty theo loi cn au m
cho thuc ph hp: + Cn au co tht: Buscopan, Visceralgin, Nospa,
atropin. + Cn au kch thch thnh bng: Peralgan, Efferalgan, bc d dy.
+ Cn au lan: phong b thuc t: Feldene. + Cn au phi hp: phi hp nhiu
thuc hoc morphin (nn dng ng liu). + Cc bin php gim au phi hp: chm
lnh, ng vin, chn t th au... - Lun ch xc nh c ch nh ngoi khoa cp hay
khng: Du hiu cn pht hin: co cng thnh bng, phn ng thnh bng, cm ng
phc mc, du hiu ca tc rut, au h chu phi. Vi cc trng hp au bng c
nguyn nhn r rng v ton trng n nh: + Gim au y . + Gi chuyn khoa iu
tr. Trng hp cha r chn on: - Loi tr cc nguyn nhn nguy him biu hin kn
o: cha ngoi t cung, v tng rng, vim rut tha khng in hnh, tc mch mc
treo, vim ti tha. - Nhng cn au bng cp cha r nguyn nhn mc d khm k v
lm nhiu thm d v xt nghim: + Cn theo di st nu cn au dai dng khng dt.
+ Lu bnh nhn nm lu li theo di (nhiu trng hp nguyn nhn ch l r sau
khi theo di nhiu gi n vi ngy). TI LIU THAM KHO 1. V Vn nh v cng s.
"Hi sc cp cu ton tp. Nh xut bn Y hc, 2007. 2. Current diagnosis and
treatment Emergency Medicine, 6thedition, McGraw Hill 2008. 3.
Rosens Emergency Medicine, Me Graw Hill 2006.
35. CP cu CN AU QUN THN CP I. I CNG au xut hin khi si di chuyn
t b thn xung niu qun. V tr au thng lin quan n v tr tc nghn. Trong
cp cu ch yu l iu tr gim au, x tr cc trng hp c bin chng v pht hin cc
trng hp cn x tr ngoi tit niu cp cu. II. CHN ON 1. Lm sng - au bng:
thng l mt bn au cn d di, au lan xung b phn sinh dc ngoi nu si vng
thp. V tr au ph thuc vo v tr si v s di chuyn ca si. - i mu: i th,
vi th hoc c th khng c. - C th bun nn, nn; i kh, i rt (si thp). - Du
hiu bin chng: nc b thn, vim b thn. 2. Cc thm d cn lm sng a. Chn on
hnh nh - Xquang h tit niu khng chun b: c th pht hin si cn quang, c
bit bnh nhn c tin s si cn quang, khng ch nh cho ph n c thai, ph n
tui sinh cn loi tr kh nng c thai trc khi chp (chm kinh, test thai),
tt nht l khng nn chp Xquang m nn lm siu m h tit niu. - Siu m h tit
niu: la chn u tay, tuy nhin c th khng thy nu si b vng thp. - CT h
tit niu khng cn quang: la chn s 1 xc nh v tr v kch thc ca si, c th
thay th cho c Xquang v siu m, c th tim thuc cn quang nh gi ngm thuc
ca thn. b. Xt nghim nc tiu - Xt nghim nc tiu: tng phn tch nc tiu
thy hng cu, nu khng c hng cu niu vn khng loi tr c si niu qun. 3.
Chn on xc nh - au qun cn vng mng sn mt bn. - Siu m h tit niu, chp
bng h tit niu hoc chp CT khng cn quang h tit niu c si niu qun. - Xt
nghim nc tiu thng c hng cu niu. 4. Chn on phn bit - Cha ngoi t cung
v: chm kinh, ra mu m o, test thai dng tnh, siu m xc nh khi v. -V
phnh ng mch ch bng: tng huyt p, i tho ng, khi phng p theo mch, ting
thi,... - Tc rut cp: nn, b trung i tin, bng trng, chp Xquang bng
khng chun b c mc nc - mc hi, khng i mu. - Vim rut tha: st nh, khng
c i mu. - Nhi mu thn: c a bnh l tc mch nh rung nh, suy tim, ri lon
m mu... chp ct lp c thuc cn quang gip chn on xc nh.
36. 50 H ng dn chn oAn va iu tr bnh Ni khoa III. IU TR 1. Gim
au - Thuc gim au chng vim khng steroid: Piroxicam (Feldene) 20mg
tim bp hoc indomethacin 100mg t hu mn. - Perfalgan 1g truyn tnh
mch. - Nu khng au, morphin 5mg tim tnh mch, nhc li sau 10 pht nu cn
au. -Thuc chng co tht: Buscopan 10mg tim tnh mch X 3 ln/ngy. - Hoc
No-spa 40mg, tim tnh mch 1 ng X 3 ln/ngy. - Hoc Visceralgin
(tiemonium methylsulfate) 5mg/2ml tnh mch 3 ln/ngy. 2. Thuc khng
sinh Nu st hoc bch cu niu hoc nghi ng nhim khun tit niu:
ciprofloxacin 200mg tnh mch 2 l/ngy. Hoc norfloxacin (2 vin/ngy,
chia 2 ln). Hoc ceftriaxon 1g tnh mch 2 ln/ngy nu bnh nhn c chng ch
nh vi quinolon. / 3. Hi chn chuyn khoa ngoi tit niu cp cu nu: - Thn
n c, si niu qun c hai bn. - Bin chng. + St. + Suy thn, v niu. + Hnh
nh: ngm thuc cn quang quanh thn; hnh m lp m quanh thn; ph n quanh
niu qun; vim thn - b thn, thn m, p xe, chm tit, thn cm. - Si >
7mm. - au khng khng ch c bng thuc. 4. Thuc ra vin v giy khm chuyn
khoa khi khng c yu cu x tr cp cu ngoi khoa - Khi c au nn ung hn ch
< 500ml/24 gi. - Feldene 20mg ung 2 vin/ngy. - Khm chuyn khoa
tit niu xem xt ly si: + Tn si ngoi c th. + Tn si qua ni soi ng tit
niu. + Tn si qua da. + Tn si qua phu thut ni soi. IV. PHNG BNH -
Ung nhiu nc. - Nu l si calci th cn gim hm lng thc n c cha calci, c
th dng li tiu nhm thiazid. - Nu l si urat th nn ung bicarbonat hng
ngy, ung allopurinol lm gim acid uric mu. TI LIU THAM KHO 1. Mary B
Fishman, MDMark D Aronson, M D (2010), Differential diagnosis of
abdominal pain in adults, Uptodate 18.1. 2. Gary c Curhan D, Glenn
M Preminger (2010), Diagnosis and acute management of suspected
nephrolithiasis in adults, Uptodate 18.1.
37. TC NG MCH PHI CP (do bnh l huyt khi- tc mch) I. I CNG Tc ng
mch phi (TMP) l hin tng tc t nht mt ng mch phi hoc nhnh ng mch phi,
thng do huyt khi t tnh mch su di chuyn ln, y l mt bnh kh thng gp
tuy nhin kh chn on v d nhm vi cc bnh khc. Kh nng chn on v iu tr ph
thuc vo trang b ca tng c s y t, d c trang thit b y , song nu khng
ngh n th khng chn on c TMP. Bnh nhn khng c chn on v iu tr ph hp c t
l t vong ln n 30%. II. CHN ON 1. Triu chng lm sng Bnh nhn c th biu
hin cc triu chng khng c hiu sau y m khng r nguyn nhn: Kh th; au ngc
kiu mng phi; ho ra mu, ngt; tt huyt p v/hoc sc. 2. C mt hoc nhiu yu
t nguy c huyt khi - tc mch Sau m thay khp gi, thay khp hng, u i
trng, u x t cung, bnh nhn ung th giai on cui, nm lu, c thai, sau ,
bnh l mu tng ng sn c... - Tnh im VVells (xem bng 6). Bng 6. Thang
im Wells STT Chs im 1 Ho ra mu 1 2 Ung th 1 3 Tin svim tcTM ch di
hoc tc ng mch phi 1,5 4 Bt ng lin tip > 3 ngy, hoc hu phu trong
vng 4 tun (cc phu thut ln) 1,5 5 Nhp tim nhanh >100 ck/ph 1,5 6
Du hiu vim tc tinh mch chi di khi khm (mt chn sng, nng, au, mch mu
chn r) 3 7 t ngh n chn on khc (khi loi tr so b ccbnh l khc) 3 Wells
> 4 im: kh nng TMP cao, ch nh ccthm d chn on hnh nh ngay chn on
xc nh. Wells < 4 im: kh nng TMPthp, cn lm thm D-dimer, nu
D-dimer 500gg/ml cn lm thm ccthm d chn on hnh nh chn on.
38. 52 Hng dn chn on va iu tr bnh Ni khoa Phc chn on v x tr n h
i m u p h i 3. Triu chng cn lm sng ca TMP - in tim: nhp tim nhanh,
rung nh, bloc nhnh phi, nng th c s su D1, Q su D3, T m D3 hoc T m
cc chuyn o trc tim phi V1-V3. - Kh mu ng mch: kim h hp v shunt pH
tng, PC02gim, P02gim, HC03 bnh thng, A-a02> 50 ( bnh nhn COPD th
PC02c th bnh thng v HC03" tng). - Xquang phi: trn dch mng phi, vm
honh nng cao mt bn, ... D.dimer: D-dimer < 500g/ml v Wells <
4 th c th loi tr TMP. - Siu m Doppler tnh mch chi di: c th c huyt
khi tnh mch su. - CT thng mch phi: gi tr chn on thp, thy huyt khi
mch l chn on xc nh; nu khng thy huyt khi th cn phi lm thm siu m
Doppler tnh mch su loi tr TMP. - MsCT mch phi: l thm d u tay thay
th cho chp ng mch phi. Chn on xc nh khi c huyt khi trong ng mch
phi. 4. Chn on xc nh -au ngc, kh th, ho ra mu, ngt khng r nguyn
nhn. - C c a bnh l huyt khi tc mch: sau m vng tiu khung, ung th, nm
lu. - in tim, Xquang thay i. - D-dimer dng tnh. - Thm d chn on hnh
nh c huyt khi ng mch phi. 5. Chn on phn bit - Hi chng vnh cp: cn au
ngc gi mch vnh, c yu t nguy c bnh mch vnh (tng huyt p, i tho ng
(T), ri lon lipid, ht thuc l, tin s gia nh), T gi , troponin v CK,
CK-MB. - Vim phi, vim mng phi: ho, st cao, cng thc mu c bch cu tng,
Xquang phi c hnh nh vim phi. - Phnh tch ng mch ch: tng huyt p, mch
t chi khng cn i, du hiu thiu mu ngoi vi, Xquang ngc trung tht rng,
chp CT ng mch ch c thuc cn quang. - Trn kh mng phi (TKMP): au t ngt
ngi tr, nghe phi r ro ph nang km mt bn, Xquang phi c TKMP. - Ph phi
cp: suy tim, suy thn mn, ran m hai bn phi.
39. 53Hng dn chn on va iu tr bnh N i khoa III. IU TR p dng iu
tr ty thuc vo iu kin thc t ca bnh vin. Yu cu kim tra k cc chng ch
nh ca bnh nhn vi cc thuc chng ng v tiu si huyt trc khi ch nh. 1. iu
tr TMP khng tt huyt p - Bt ng ti ging 24-48 gi cho n khi thuc chng
ng c hiu qu. - Th 0 2nu Sp02< 95%. - Enoxaparin (Lovenox) 1mg/kg
tim di da 2 ln/ngy (t ngy 1), dng sau 5 ngy iu tr v INR 2-3 lin tip
2 ngy. - Sintrom 1mg/ngy (ngay t ngy u tin), lm INR u tin sau 3 ngy
bt u iu tr, iu chnh tng gim liu sintrom xung 0,5mg/ngy t ch INR
2-3. Nu INR > 3, khng c chy mu ng k th cn b liu tip theo, sau
quay li vi liu gim i 1/8 vin hoc lun phin v d 1/4 -1/8-1/4 -1/8
vin. - Natri clorua 0,9% X 500ml (truyn tnh mch 20ml/gi). 2. iu tr
TMP c tt huyt p hoc sc - Hi sc h hp nu c suy h hp. - t ng truyn tnh
mch ngoi vi chc chn ti v tr c th bng p (trnh t catheter tnh mch
trung tm hoc ng mch). - Heparin: bolus 5000UI trc Actilyse, sau kt
thc Actilyse th truyn duy tr 500UI/kg/ngy (duy tr t nht 5 ngy, sau
dng li khi khng vitamin K c kt qu). - Truyn tnh mch Haes-steril 6%
500ml trong 20 pht (sau khng ch dch). - Dobutamin: 5g/kg/pht (tng
mi ln 2,5g/kg/pht sau 10-15 pht) hoc dopamine 5g/kg/pht (tng mi ln
2,5g/ kg/pht sau 10-15 pht). Mc tiu huyt p > 100/70mmHg. - R sot
li bng kim cc chng ch nh dng thuc tiu si huyt trc khi quyt nh truyn
Actilyse cho bnh nhn. - Actilyse: 0,6mg/kg trong 20 pht bm tim in
phn ph lc. - Gi khng vitamin K nh TMP khng tt huyt p (ngay t ngy u
tin). Trong trng hp bnh nhn c chng ch nh thuc tiu si huyt hoc dng
thuc tiu si huyt tht bi, cn chuyn bnh nhn n c s c kh nng m m ngc ly
huyt khi. 3. Phng bnh - Vt l tr liu, trnh nm lu. - VI bnh nhn c yu
t nguy c cn dng thuc chng ng d phng bng heparin trng lng phn t thp
hoc khng vitamin K. - Sau phu thut nn cho bnh nhn tp i sm. TI LIU
THAM KHO 1. B Taylor Thompson (2010), Overview of acute pulmonary
embolism, Uptodate 18.1. 2. Guidelines on the diagnosis and
management of acute pulmonary embolism, ESC. 3. Guidelines European
Heart Journal (2008) 29, 2276-2315,Protocol des Urgences du DAU de
Ihopital Hotel Dieu, Nantes- France 2009.
40. 54 Hng dn chn on v iu tr bnh Ni khoa PH LC Bng 1. Tnh liu
truyn Actilyse (50mg trong 50ml tng ng 1 mg/ml) Cnnng(kg)
Tngliu(mg) Thtchcntruyn(ml) Tctruyn(ml/gi) 40-45 26 26 78 46-49 28
28 86 50-55 32 32 96 56-59 34 34 104 60-65 38 38 114 66-69 40 40
122 70-74 44 44 132 75-79 46 46 140 >80 50 50 150 Chng ch nh
thuc tiu si huyt (theo khuyn co ca Hi Tim mch chu u) a. Chng ch nh
tuyt i - ang c chy mu ni tng. - Mi xut huyt no. b. Chng chi nh tng
i - Sau i phu, sau , sau sinh thit tng hoc chc mch ti v tr kh bng p
trong 10 ngy gn y. - Nhi mu no trong 2 thng gn y. - Chy mu d dy-t
trng trong 10 ngy gn y. - Chn thng nng trong 15 ngy gn y. - M thn
kinh hoc mt trong vng 1 thng. - Mi hi sinh tim phi. -Tiu cu thp
< 100.000/mm3, prothrombin < 50%. - C thai. - Vim ni tm mc
nhim khun. - Bnh xut huyt vng mc do i tho ng. Bng 2. Phc dng Heparn
cho bnh nhn TMP cp Phathuc:25.000v/500ml (50v/ml) Bolusbanu:
(80v/kg): 4.800v Duytr banu:(18v/kg/gi): 1.100v/gl(22ml/gi) APTTgiy
Thayi v/kg/gi Thaotc KimtraAPTT < 3 5 (1,2 ln chng) Tng ln 4
(250 v) hoc 5ml/gi Bolus li 80 n v/kg (4.800 v) Sau 6 gi
35-45(1,2-1,5) Tng ln 2 (100 v) hoc 2ml/gi Bolus li 40 n v/kg
(2.400 n v) Sau 6 gi 46-70(1,5-2,3) Khng thay i Sau 6 gi
71-90(2,3-3,0) Gim xung 2 (100 v) hoc 2ml/gi Sau 6 gi
